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Therapists and teachers often describe their approach to psychotherapy as a system or method, such as cognitive-behavioral or psychoanalytic. Many other approaches, when you look into them, are some sort of inspired hybrid, such as Emotion-Focused Therapy, Internal Family Systems or Acceptance and Commitment Therapy.My approach to therapy, like my approach to consultation with therapists, doesn’t rely on a system or a method, although it is methodical and systematic in its own way. It places experience, and the observation of experience by client and therapist, first. In my work with each client in psychotherapy, and each therapist in consultation, I am focused on exploring the experience of the client, the experience of the therapist, and the experience of the therapeutic pair. This is a highly reflective process, and it includes the exploration of behavior and its meaning. Psychologist George Kelly–a teacher of one of my teachers–said, “Experience is not what happens to us, it’s what we do with what happens to us.”

I had a very unusual introduction to psychotherapy, because of coincidences (or, if you prefer, luck, or grace) in my life. While still an undergraduate at Goddard College, in Plainfield, Vermont, I met, and became an apprentice to, Eugene Eliasoph, MSW, LCSW, co-founder and co-director of the New Haven Center for Human Relations. Gene was a therapist, psychodramatist and leader of therapy and personal growth groups. For a year, II was able to participate in Gene’s groups, along with licensed therapists and Yale post-docs, and receive undergraduate credit for an off-campus field experience.Goddard’s educational philosophy, influenced by John Dewey, prioritized experiential learning and the role of students in pursuing what they wanted to learn, on campus and off.Even then, I was finding my own way.

Psychodrama, for readers unfamiliar with it, is a way of exploring situations in our lives, in groups, by acting them out rather than talking about them.The person whose situation is being explored is the “protagonist,” the leader is the “director,” and group members play the various people involved in the situation.There is a role in psychodrama called “auxiliary ego,” which Gene often asked me to play.The auxiliary ego, also called a “double,” is sent by the director to join with the protagonist (or other member of the psychodrama) and express what the person might be thinking or feeling, but not saying.This was part of my introduction to psychotherapy.The experience of the person I was doubling with was more important than any theory, method, concept or system. My task wasn’t to label what the person was struggling with, or analyze how they were doing it, it was to find my way into the person’s experience and express it in a way that helped move the exploration forward.

In his other therapy and personal growth groups, Gene included me as a “model member,” who was there to learn and participate authentically. Gene had a lot of knowledge and experience about facilitating therapeutic and personal learning in groups, and later became President of the American Society for Group Psychotherapy and Psychodrama. His focus was always on the experience of the people he was working with, and he had a way of being and working with them that helped them feel encouraged and secure enough to explore issues that might otherwise have felt too vulnerable and disorienting to get into.He had psychoanalytic training, at both Austin Riggs and William Alanson White, as well as psychodramatic training with J. L. Moreno, the creator of psychodrama; all of which informed his work. But he also bought his own life experience to his work. Among other experiences, as a soldier in W.W. II, he had been captured and escaped, and this contributed to a deeply existential view of human nature.He had also been influenced by the writings of Harry Stack Sullivan, which he had studied at William Alanson White (which Sullivan had helped found), on the importance of interpersonal relationships. Gene was also a jazz musician, as I was at the time–he on clarinet and me on guitar–and we shared a love of improvising together within a structure. This is similar, in some ways, with the experience of psychodynamic psychotherapy (for a unique consideration of this dimension of therapy, see “The Musical Edge of Therapeutic Dialog,” by Steven Knoblauch, https://www.amazon.com/Musical-Edge-Therapeutic-Dialogue/dp/088163297X).

I later came to understand part of Gene’s systematic approach in the psychoanalytic concept of the “frame” of psychotherapy. The frame is the set of mutual roles and responsibilities of client and therapist, which creates a safe relational space, at least compared with most other relationships in our lives, within which clients can let down their guard and accept help in exploring intimate and difficult issues.

Later on in my academic and professional education, I was exposed to lots of theories, methods, and systems of therapy. They all seemed to me to have some truth, mixed up with expressions of the personalities of the founders and their followers, and their attempts to achieve stature and the appearance of theoretical consistency. This is a problem that started with Freud and continues to this day. I’ve worked around it by studying neuropsychology and neurocognitive science, as well as spiritual psychology, and developing a model of how psychotherapy works. That model, under continuous revision, is based on brain structure and function, neural networks and their interaction, the experience and behavior of multiple self-states, the social and economic dynamics of human communities past and present, the dynamics of identity and meaning, and how all those processes are instantiated in the client’s issues and the psychotherapeutic relationship. (See my review of Pat Williams’ “Which You Are You?” https://psychatlarge.com/a-review-of-which-you-are-you-by-pat-williams/). I call it an “expanded psychodynamic” model, and it easily incorporates what I find useful in psychoanalytic, cognitive, and other therapeutic approaches. It enables me to be methodical and systematic without being confined within any method or system.

For more on consultation to refine therapists’ perceptions and skills, see my earlier blog post at https://psychatlarge.com/consultation-to-refine-therapists-perceptions-and-skills/

I’m not a “one size fits all” psychologist—quite the opposite—but one of my favorite one-stop teachings about human nature and therapy is “Which You Are You?” by Pat Williams. Originally released as a spoken CD by Human Givens Publishing, in the United Kingdom, “Which You Are You” is now available as an mp3 from the Human Givens website, https://www.humangivens.com/category/cds-mp3s/mp3s.

Williams begins “Which You Are You?” with a kind of “human given:” “Every one of us, and we see it the minute we think about it, has many ‘minds’ rather than just one…These divisions in our psyches are a matter of daily personal experience. We are unmistakably made up of many self-contained personalities, some of which are helpful allies, some delinquent or even at war with each other, andsome of which we are utterly unaware.” Although “we think of ourselves as whole,” our real condition is a continuous transition of “what psychologists call sub-personalities.”

The basic idea is not new. “Unsurprisingly, the knowledge of sub-personalities is in fact centuries old, found in many traditional religious and esoteric practices, and presented in various forms,” including the differing characters of the Hindu gods, and the beliefs of ancient Greeks, “who saw humans as intrinsic to the dramas of the many gods above.” In medieval times, “people believed that they could become possessed by a whole bestiary of demons, devils and imps…capable of causing disabling mental states…We find it too in the Gospel according to Mark, when Jesus meets a man possessed by demons. When asked for his name, he replies, ‘My name is Legion, for we are many.’”

Coming up to the present, “When we come to relatively modern times, and look at Western psychology, we find Freud describing personality as a continuing struggle of elements within a divided mind, and Jung talking, even before Freud, about divisions in the psyche. We see the ideas surface in Maslow’s work, and in (Roberto) Assagioli’s, where the work is to unify the sub-personalities. It’s there in the work of Gurdjieff, and in quite a bit of the psychological literature in recent decades.”

Multiplicity of personality reflects the structure and function of the brain. Williams introduces “Multimind,” the 1986 book by psychologist Robert Ornstein, saying “I think he may be the first in modern times to make the connection that our multiple selves, some of which are valuable allies, and others of which can give us a great deal of trouble, are actually a reflection of how we are made. Given the machinery of the brain, it could hardly be otherwise.” https://www.amazon.com/gp/product/1883536294/ref=ox_sc_sfl_image_1?ie=UTF8&psc=1&smid=ATVPDKIKX0DER

This dovetails with my own view of personality; not surprisingly, since “Multimind” is foundational to it. My “elevator speech” about therapy is: “Personality exists in parts, as neural networks in the brain, adapted to the conditions in which we grew up. When circumstances change, and the parts and configuration are no longer adaptive, we have to revise and reconfigure them. That’s what therapy is for.”

Williams notes the look of surprised recognition in her therapy clients when she describes this view of personality. “The fact that we are a congregation of minds, many (of which) have no idea of, or even interest in, what another of their number is doing, is so familiar that we take it for granted.” She invokes Walt Whitman: “Do I contradict myself? Very well then, I contradict myself. I am large, I contain multitudes.”

The “small minds” are “states of locked, internal focus; in other words, trance states.” This recognition helped generate a metaphor in Williams’ work with a client, which she has since used often with other clients. This woman loved opera, and Williams drew the distinction between opera, in which there can be several characters on stage at one time, following directions, and the “opera of our lives,” in which “we normally can have only one character on stage at a time, and sometimes it’s the wrong character” for the situation, “hogging the spotlight and refusing to stop singing or get offstage.” Similar metaphors—a ship and its crew, for example—have provided ways of helping clients to achieve a distance from their problem, and take “greater, sometimes almost exquisite, control over their own states of mind.”

The sub-personalities don’t become the whole focus of therapy in William’s approach; bringing up the metaphor when needed makes it more powerful. The “observing self,” described by psychiatrist Arthur Deikman, “equates with the director of the show,” while “positive and negative trance states and emotional arousals are the characters. Clients are thus separated from their problem,” and their resources for self-awareness and self-regulation can be “recognized, named, and brought into play.” Williams encourages her clients to name the various parts of themselves—playfully, not too seriously— that claim the stage. One of my clients, using this method, identified “The General,” who comes onstage whenever he feels slighted, while another client identified the “C.O.O.” (chief operating officer), who takes over in the absence of a C.E.O. (chief executive officer). Another metaphor I’ve found useful in therapy is that of an orchestra and conductor, used by neuropsychologist Elkhonon Goldberg to describe the role of executive functions (the conductor) in his The New Executive Brain. https://www.amazon.com/New-Executive-Brain-Frontal-Complex/dp/0195329406/ref=sr_1_1?s=books&ie=UTF8&qid=1514583481&sr=1-1&keywords=the+new+executive+brain+frontal+lobes+in+a+complex+world

“Naming anything…brings a measure of control,” Williams says, “and this is certainly true in the case of the characters. Naming the character requires the client to move into his or her observing self to take a look.” Williams highlights the “power of naming,” to shift the locus of control. “Once you’ve named them, then whenever you feel disturbed in some way, you can quickly identify which small mind is creating this impact, and become aware that you need to move it out of the way.” Williams then gives several examples, from her work with clients, of how identifying sub-personalities, such as “Valerie Victim”—essentially states of mind established long ago in response to circumstances that no longer apply—were usurping control and undermining them. By helping her clients identify their sub-personalities and then learn to direct them, Williams helps her clients reclaim control over their inner lives; for example, by replacing “Valerie Victim” with “Confident Connie.” Each character brings its own style, varying in attunement to our current situation and needs, replacing the one on stage before. “Whenever a new character arrives, the one before is forgotten,” Williams says; recalling, for me, Elkhonon Goldberg’s description of consciousness as, “a neural network operating at a sufficient intensity for a sufficient period of time.” When one neural network replaces another, consciousness changes.

Williams describes self-undermining states as emerging from “An over-alert amygdala, pattern-matching traumatic memories to vaguely analogous situations…The whole point of drawing attention to these switches is to help people break out of imprisoning trances, and also develop an ease and flexibility which allows them, deliberately and consciously, to shift between states, or to pull back into the observing self.”

Because we have this kind of personality structure, we are always vulnerable to one self-state coming forward to dominate the others. “We all know people in whom one character, self-pity maybe, or a dominator, is more or less permanently on stage.” Williams gives several examples from her work with clients of the importance of our becoming capable of identifying such controlling selves, moving them off stage, and replacing them with selves who are more attuned to, and competent for, the situation we are in.

The metaphor of an opera can be effective in couples work too. “Even if two people love each other, some of their characters may still be slugging it out.”

These inner characters—states of self—have their own attitudes and histories, plusses and minuses. Sometimes the state we need isn’t available in our internal array, so we have to import it, as it were, from outside; from people we know who can be, for example, good at interviews. “Identifying with the psychological skills of others…connects us with the same potentials in our own minds.”

“Which You Are You” envisions the goal of our being in the right state for whatever situation we are in. “What you’re learning is that you can bring whatever character you need on stage, allowing you to handle a situation skillfully. And you’re also learning how readily a mismatch between a part and a situation can generate problems…What an extraordinary sense of control and personal power, when you know and appreciate all the different parts of yourself.”

It’s important not to be too perfectionistic or serious about this. “In all of this…a light touch is crucial, an essential safeguard against self-absorption or pretentiousness.” Keeping it light helps us regain our balance. “When we have identified sufficient characters in the dramatis personae, we can look at any of them evenly, without judgment…Lighthearted naming lessons tension and helps pull us back into the observing self…Any of the characters can be allies, just as long as we have them rather than them having us.” And, “Any character will hold up the show…if something else is needed…I have never seen anyone, after encountering their ‘opera,’ exclusively identifying with any character, although they may have done so…before that.” Williams quotes Nietzsche, : “Woe to the thinker who is not the gardener, but only the soil of the plants that grow in him.”

Williams, like Deikman, has a spiritual perception at the core of her understanding of personality. The approach that she’s describing “leaves the essence of what we are, the heart of us…always intact. Who we are can perhaps be thought of as partly material, partly transcending that, but it is always safe, because it is the bit that nobody can ever get at…Awareness of our many minds opens up a trail leading well beyond the bounds of therapy.”

In addition to being “an invaluable, commonsense way of helping us begin to know our many selves,” this approach helps us to know others too, Williams says. “Societies and nations have their multiminds too, and operas of their own. I sometimes think that if we were able to identify and manage their characters, with the same purpose, clarity and success that we can learn to manage our own, how different perhaps the life of human communities might be.”

I LOVE this presentation, because it contains so much useful information about our minds and how we get stuck and can get unstuck in our lives. “Which You Are You?” illuminates human nature and experience as they are, rather than trying to fit them into some dogmatic theoretical, philosophical or other package, as so many presenters on therapy and human nature do. Much as I love it, however, I have two hairs to split, and a bone to pick, with “Which You Are You?”

First, Williams uses the word “psychodynamic” as a synonym for “psychoanalytic,” as many psychoanalysts and others do, in order to differentiate her approach. But if we understand “psycho-dynamic” as I prefer to, to include any model of mind in which parts are engaged in dynamic (energized) relationships, “Which You Are You?” fully qualifies.

Second, there sometimes seems to be a nuance of difference between how Williams uses the term “observing self” and how I understand Deikman to have used it. Deikman was an investigator of the mystic tradition as well as a psychiatrist; the subtitle of his “The Observing Self” is “Mysticism and Psychotherapy.” https://www.amazon.com/Observing-Self-Mysticism-Psychotherapy/dp/0807029513/ref=sr_1_1?s=books&ie=UTF8&qid=1514583673&sr=1-1&keywords=the+observing+self+deikman He distinguished between the “object self,” which can be viewed like any object, and the “observing self,” pure awareness, which cannot be seen as an object. When Williams advises her client that “They (the sub-personalities) come and go, you are always there…You are the same person you always were, and that’s all we can say about it,” she is drawing from this well. Yet she also sees the observing self as a director, switching selves on and off the stage, which seems to me to be an object function. This is something that I’ll need to meditate on.

Third—this is the bone to pick—Williams’ case examples seem to suggest that therapy can be done on a short-term basis with complex clients through the application of metaphors of self that include multiple parts under some sort of direction, in the context of a supportive and guiding therapeutic relationship. In therapist peer study groups I facilitate, when we’ve discussed “Which You Are You,” my colleagues welcomed its description of mental life and use of metaphors in therapy, but didn’t see how that would lead to successful brief treatment with most of the clients with whom we are working.

In “Which You Are You?,” Williams is speaking from the Human Givens approach to therapy. Human Givens is a short-term treatment approach which encourages the therapist to get right in there and deal with what’s happening with the client. That’s great, but I haven’t seen, in the Human Givens approach, a recognition that clients can present with multiple complex issues that may have to be discovered and dealt with in therapy over time; reflecting clients’ need to develop psychological capacities they didn’t possess, to the necessary extent, when entering therapy.

“Which You Are You?” presupposes a fairly highly developed ability, on the part of our clients, to detach from their sub-personalities and observe them in action, given therapeutic guidance. Many of our clients, however, don’t come to therapy with much of that ability, so the dynamics of the sub-personalities, as they affect the issues that the client has come to therapy for, may take time to become evident to client and therapist; sometimes a long time. For example, a client with whom I’ve been working for over five years, with an early traumatic history that itself had taken some years to emerge in therapy, has only recently begun to identify a kind of vigilant guardian self that has been firmly in control throughout much of his life, protecting him and others at the cost of greatly restricting his experience of self and others, and his capacity for relationship. Another client, with whom I’ve worked for over ten years, listened to “Which You Are You?” perhaps three years into his therapy. He immediately grasped the principle of the of the selves, and it has contributed often and meaningfully to the value and depth of our therapeutic conversation, but it hasn’t shortened it. It’s great when therapy can be brief and successful, but it’s by no means, well, a human given, that it will be. The parts of our personality are neural networks in the brain, and so are the abilities to observe and redirect them. It can take time to grow the neural networks to observe, adapt and redirect the neural networks that are the sub-personalities.

In fact, “Which You Are You?” has a lot to contribute to psychodynamic therapists who do long-term work, like me. One contribution is to deliberately focus the therapy on the cultivation of, and access to, the observing self. In my view, this is often more of an unintentional side-effect of therapy than a main focus, but it is responsible for much of the actual value of most therapy. Another contribution is to help therapists avoid approaching our clients with theoretical presuppositions about what the parts are—ego, id, superego, Oedipal complex, archetypes, for example—and instead to keep an open mind to discovering them as the client experiences them, in the collaborative therapeutic relationship.

“Which You Are You?” is a favorite single source of information about how our minds work and what our experience is really like. I regard it as a better source of information about what really happens in the psychological dynamics of our lives, and how we might reorganize them adaptively in therapy, than most of the books I’ve ever read about therapy, put together.

I’ve just completed presentations on consultation for therapists at the annual conferences of three professional associations: The National Association of Social Workers- Illinois Chapter, the Illinois Psychological Association, and the Illinois Counseling Association. Each presentation was organized around a lecture/slide show about consultation, and included a live demonstration in which I provided consultation to a volunteer therapist consultee. Each presentation also had its own emphasis: more information about consultation, and psychodynamic and cognitive-behavioral concepts, for the NASW-IL; less focus on consultation in general, in order to allow for an additional focus on trauma-informed consultation, for IPA; and less focus on consultation in general, in order to allow time for participants to practice peer consultation with one another, at ICA. Each of the programs went well, based on participant engagement, comments, and the feedback I’ve received. In this post, I’ll cover some of the consultation presentation, with the caveat that the live demonstration is what makes it really, well, come alive.

There is an infinite amount of learning about how to do therapy that mental health professionals can explore and accomplish after achieving licensure. Consultation is a key way for working therapists to inform and refine our therapeutic awareness, perceptions and skills.

Consultation is not supervision, which has specific legal meaning in licensure law for each profession. In supervision, the supervisor, or program for which the supervisor works, is clinically and legally responsible for the supervisee’s work. The supervisor is a professional gatekeeper who is responsible for evaluating the supervisee’s qualification to enter the field. Supervisees cannot select their supervisors at will, and may have to work with supervisors whose therapeutic styles, methodological preferences, and theoretical commitments are not a good match for their own talents, skills or interests. Nor can supervisors select supervisees; they may have to work with supervisees in whom they have little confidence, or about whose talents and abilities they may have doubts, due to program commitments. And supervisees have to work under supervision for a legally designated number of hours in order to be eligible for licensure.

Consultation, on the other hand, is a relationship between independently licensed professionals, which aims at informing and refining the consultee’s therapeutic awareness, perceptions and skills. It confers no formal certification and is entirely at will. Consultees can select any consultant they’d like to work with who will work with them (and with online consultation, their consultant can be anywhere in the world). Frequency of meeting is up to the consultant-consultee pair; weekly, every other week, every third or four week, etc. There is no required amount of time for consultation; it continues until either or both parties decide to stop. Basically, we select people to consult with from whom we can learn.

There are different types of consultation. Mentoring consultation is a teacher-and-learner relationship, in which the consultee works with a consultant from whom the consultee has something to learn. In peer consultation, colleagues consult on an equal basis for mutual benefit. Either mentoring consultation or peer consultation can take place on a 1:1 or group basis, and either form of consultation can be time-limited or ongoing.

In addition to types of consultation, there are styles of consultation. The length of time the consultee prepares to present a case can vary from none (a completely spontaneous presentation) to some (some forethought, review of therapy notes, making some notes to present from), to extensive (preparation involving hours of writing and pages of text). The length of time after the consultee begins presenting the case, before the consultant (or, in a group, consultants) begin to engage by asking questions or making comments, can vary from a few minutes to half an hour or more. Some consultation is strictly within a particular theoretical model, while other consultation uses any model of mind, and of how therapy works, that helps to make sense of the cases and experiences which consultee and consultant are discussing. The amount of coherence expected in the consultee’s presentation of the case can also vary. My preference is not to expect too much coherence, because that risks the consultee and consultant trying to make the therapy fit a particular theoretical model. I prefer to allow coherence to emerge in the discussion of the experience of the therapist, the experience of the client, and the experience of the therapist-client pair.

What do consultants and consultees talk about? We talk about the client’s situation, history and experience, past and present, outside the therapy office. We also talk about the client’s experience, feelings and behavior in the therapy office, and the therapist’s experience of being with, and working with, the client. We talk about how the therapist understands the client, and her therapeutic relationship with the client, and about areas where the therapist feels confused or stuck; and ways the consultant might see the therapy that the consultee is describing.

We also talk about the “frame” of the therapeutic relationship, which means the therapeutic, economic and professional roles and responsibilities of the client and therapist to themselves and each other in their work together. This includes such areas as late arrival, extending sessions, missed payments, missed sessions, control of the focus of the conversation, etc. We talk about the therapeutic agreement or contract, meaning the goal(s) or purpose(s) of therapy, and whether they are clear, achievable, and agreed by client and therapist. A lot of therapy takes place in a kind of preliminary phase, where the goals and purposes of therapy are, at best, implicit and emerging. Clarifying goals itself can be a therapeutic process.

From psychoanalytic culture comes the idea that there are two levels of therapy. The first is where the client receives the attention, respect, caring, concern, presence and empathic support of the therapist. These are all necessary ingredients of the therapeutic relationship, and that can often be as far as the therapy goes. The second is where the therapy is providing that support and also making it possible for the client to work on her- or himself. This means that the client is looking at his own issues outside the room, in life outside of therapy, as well as inside the room, in the therapeutic relationship. Some analysts call these two levels the supportive relationship and the analytic relationship. I’ve referred to them as the supportive relationship and the working relationship, in order to make headroom for work, with and on the self, that may include, and also extend beyond, the traditional mental models of psychoanalysis. Consultation can help therapists establish the first level, and then co-create bridges, with their clients, to the second.

Since consultation is so valuable, why isn’t it more widely known, recommended and practiced? Part of the explanation lies in the fragmentation of the world of psychotherapy, in which people in different therapeutic cultures keep pretty much in their own silos. Psychoanalytic culture does feature what it still calls supervision, even after licensure and certification. But that culture tends to be wrapped up within itself, and affords few points of entry for mainstream therapists who don’t wish to steep themselves in its theories, terminology, or fealty to Freud or other iconic figures. Jonathan Shedler, a leading psychodynamic researcher and practitioner, commented that he had learned, from teaching therapy to beginners, that if he couldn’t explain what he meant to them in ways they could understand in the context of the therapy they were doing, that meant he didn’t understand it well enough. “If you’re only talking to other people steeped in the same history and traditions, you operate on the assumption that you both understand what you are talking about. I thought I understood (basic psychodynamic concepts) until I had to explain them to someone who wasn’t steeped in that tradition, and I floundered with it” (personal communication). He emphasized that it’s up to consultants to “bridge the gap” between what they know and what their consultees need to learn.

Cognitive-behavioral therapy, on the other hand, has tended to be narrowly focused on specific conditions and treatments, allowing little space for the complexity of human experience involved in the exploration of relationships, identity and meaning. Nor has it tended to recognize the potential wellspring of learning that can be harvested from the complexity of the client-therapist relationship itself. That is beginning to change with the development of hybrid treatments like Dialectical Behavioral Therapy and Acceptance and Commitment Therapy, but a narrow focus on problems and goals tends to be characteristic, as does the role of the therapist as director rather than collaborative guide in the work. What’s needed is a general practice of consultation beyond therapeutic silos, by consultants who can add value to consultees without requiring them to spend years acquiring a new culture–most of which will be irrelevant to them–or to trim and package their work with clients to fit within a silo’s theoretical framework.

Therapy cultivates reflection: the client’s reflection on himself, the therapist’s reflection on the client, and both client’s and therapist’s reflection on their therapeutic relationship. Consultation adds another dimension of reflection, in which the consultant helps the therapist reflect on herself. her client, and their work together. The therapist “polishes the mirror” for the client, and the consultant “polishes the mirror” for the therapist.

Personality disorders are diagnoses made from clusters of behaviors, so it’s a different sort of diagnostic category compared to, for example, affective disorders like depression or anxiety. People with personality disorders can be depressed and anxious, but those states tend to come and go pretty quickly, and the overall behavior becomes more salient than the moods.

Personality disorders can be seen as exaggerations or crystallizations of tendencies which can be quite useful in moderation. For example, a little obsessiveness makes us careful and thorough; too much and we have to wash our hands 50 times because there might be a germ we missed. A little suspiciousness helps to protect us from being taken advantage of; too much makes us paranoid. A little narcissism gives us self-confidence; too much and we are all about self-importance. A little flexibility and reactivity can support spontaneity, adaptiveness and creativity; too much and we can have borderline personality disorder.

Here’s the list of characteristics of borderline personality disorder from the DSM-V:

“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•Frantic efforts to avoid real or imagined abandonment.

•A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

•Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria [distress, unease], irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Personality disorders, like most mental disorders, occur along a spectrum of intensity and severity. Some people have a “borderline style,” are borderline-ish or have borderline tendencies, while others may have the full-blown disorder; and of course stress can push a tendency or style into a disorder.

People with borderline personality styles or disorder often improve from the late 20s through the 30s and into their 40s, which is when the prefrontal cortex undergoes adult maturation. That tends to be the time when therapy can be most useful, probably because the person is more able to do self-observation, and exercise inhibition of impulsivity, two executive functions associated with the prefrontal cortex. It seems likely that there’s some relationship between an immature prefrontal cortex and other parts of the brain involved in borderline personality; although we can only speculate, for the time being, about what that might be.

Just because people have the same diagnosis doesn’t mean that they are the same kinds of people. There can be variations in how likable and personable, generous or mean-spirited, humorous or dour, and even wise, people with borderline personality disorder can be. This is true of any mental illness; for example, everyone with depression isn’t alike.

Because of the tendency to see others in a black-and-white, caring/helpful or hating/destructive way, people with more extreme borderline personality disorder tend to split people in organizations into supporters and opponents. Inpatient or residential mental health programs typically will inform staff if a borderline patient is admitted so that staff will use extra care to check on all communications that might have the effect of pitting one staff member against another. The ability, on the part of the person with borderline personality style or disorder, to see other people in their human complexity rather than in black-and-white, good-and-bad terms, is a sign that the person is healing or maturing.

“As the world becomes more confusing, seemingly controlled by vast impersonal forces (e.g., “globalization” or “collateralized debt obligations”) that no single individual can fully bring within view; as the normative expectation becomes to land a cubicle job, in which the chain of cause and effect can be quite dispersed and opaque; as home life becomes deskilled (we outsource our cooking to corporations, our house repairs to immigrant guest workers); as the material basis of modern life becomes ever more obscured, and the occasions for skillful action are removed to sites overseas, where things are made; to sites nearby but socially invisible, where things are tended and repaired; and to sites unknown, where elites orchestrate commercial and political forces—when all of this is the case, the experience of individual agency becomes somewhat elusive. The very possibility of seeing a direct effect of your actions in the world, and knowing that these actions are genuinely your own, may come to seem illusory.”

In this passage, Matthew Crawford identifies a fundamental issue underlying much mental disorientation and emotional turbulence in our lives. You won’t find it in the DSM (Diagnostic and Statistical Manual) or the ICD-10, the main sources of mental diagnosis in the Western world, but the lack of individual agency is a huge source of what becomes mental illness and emotional disorder, and also of susceptibility to the messages of cults and terrorist organizations. We all need feel that we matter, to ourselves and others, that our decisions and actions can make a difference.

In psychotherapy, clients often feel helpless to be agents in their lives; in their personal and family lives, in their careers, and in the economic and political currents that sweep through communities and nations. For psychotherapists, the experience of agency in helping others, one by one, is often part of what motivates our choice of profession.

For clients, the lack of the experience of agency can contribute to depression, anxiety, and passivity, on the more withdrawn side of the spectrum of temperament, or to impulsivity, intoxication, addiction, and seeking intense experiences as ends in themselves, on the more active side. For psychotherapists, mistaking prompting clients into emotional experiences, provoking changes in how they think or feel with various techniques, or getting them to agree with how we think they should see themselves, can likewise be mistaken responses to the need to feel that we matter.

For psychotherapists, helping clients to find their own ways of mattering, of becoming agents in their own lives, is a longer, slower, less exciting, but ultimately truer and more rewarding, way to really matter. But we are swimming against the current of modern life in this endeavor. Most of us, including clients and therapists, live in a world that increasingly undermines and neutralizes our natural motivation to be agents in our lives, to matter in the lives of others.

The Parliament of the Religions of the World—often shortened to the Parliament of World’s Religions—was first held in Chicago in 1893. A century later it was reconvened in Chicago (1993), and has been held four times since; in 1999 (Cape Town), 2004 (Barcelona), 2009 (Melbourne), and in Salt Lake City in October of 2015. My presentation on “Psychotherapy, Religion and Spirituality” was among the many programs.

The Parliament is an event that is certainly like no other I’ve heard of; thousands of people from all over the world convening to participate in what looks like hundreds of presentations, emphasizing the sacred in our relationships with the natural environment, the economy, people around the world, one another, and ourselves. The sheer diversity of people, and the wonderful diversity of attire, was a visual feast!

Women’s identity, equality, empowerment, and sacredness, was a theme of this Parliament. For example, I am writing these notes in a long hallway whose walls are filled with dozens of vivid silk hangings of representations of sacred women and goddess figures from several traditions.

I attended a program called “Changing Tides,” presented by a panel including Barbara Morgan (Church of Jesus Christ of Latter-day Saints, chaplain at MIT and Harvard and assistant professor at Brigham Young University), Lucy Forster-Smith (Presbyterian, Head Chaplain at Harvard University), Maytal Satiel (Jewish chaplain at Yale), in which these chaplains at major universities discussed their experiences with changing attitudes and needs in the students with whom they work. More students are identifying as “spiritual but not religious,” or, if identifying as religious, still want to learn about other faith traditions. Even among chaplains, I was surprised to learn, there are some who do not identify with a specific faith tradition.

The Plenary 1 session was entitled “Focus on Women,” and featured addresses by women of several faiths who have achieved prominence in education, administration, human service, care of the earth, and nurturing in faith and in the spirit, including Dr. Serene Jones, president of the Union Theological Seminary in New York, Grandmother Mary Lyons, an Ojibwe Elder, and several others. I was blown away by Marianne Williamson’s address—what a smart powerhouse!—in which she challenged the faiths represented at the Parliament, as often being responsible for the subjugation of women. This was a particularly gutsy observation in a gathering of people advocating that the principles of their faiths support the equality, empowerment, and sacredness of women. Williamson spoke her piece forcefully, and received enthusiastic applause.

In the programs that I attended, the emphasis on women’s natural sacredness and oppression was powerful, but seemed one-sided in a way. The implication often seemed to be that, if only society would stop being so wretched in abusing and suppressing women, women would assume their natural role as sacred healers, nurturers, and goddess-types. The learning, the effort, the self-confrontation, the sorting-out of the essential from the superficial, identifying what really matters most from what one has been conditioned to believe, getting past errors in perception and action acquired along the way, finding and living one’s way into a fuller life—which every human being has to do, and which each of the speakers undoubtedly had to do, in order to achieve her accomplishments and role in life—seemed somehow to be taken for granted, not included in the narrative.

My presentation was part of a two-part shared presentation, which began with “Diversity and Interfaith Dialog in Counseling and Psychotherapy.” The panel of presenters included three who are active in the Pagan tradition—little did I know that there was such a tradition, so developed!—including Shel Skau, the moderator, Drake Spaeth from the Chicago School of Professional Psychology, and the very impressive Vivianne Crowley. My presentation, “Psychotherapy, Religion and Spirituality,” followed, and seemed to go quite well; the audience seemed to be attentive, most stayed throughout the presentation, there were more people than seats (some sat on the floor, in a room seating about 50) and people laughed at the right places, always a good sign!

As I left the huge Salt Palace convention center for the last time, I passed a scruffy, disheveled looking young man, long-haired and bearded, sitting on the ground by a tree, surrounded by a bunch of signs that ran up the tree, with various aphorisms. One was about turning knowledge into action, which is certainly a key theme in spiritual life, and in psychotherapy too: we rarely learn things about ourselves in therapy that we didn’t know, in some way, before, but weren’t acknowledging and living. It seemed to me that this man was himself exemplifying what his sign said we shouldn’t do; as if he believed that, sitting on the sidewalk with his signs, he was turning knowledge into action. He was a living sign, albeit unconsciously.

CAPP Conversations are a series of conversations for psychotherapists by the Chicago Association for Psychoanalytic Psychology. Here is the March Conversation:

Society, Self, and Psychotherapy

A CAPP Conversation

Shunda McGriff, M.S. Counseling, LPC, NCC, Jay Einhorn, Ph.D., LCPC

March 17th, 10:00-11:30 AM

Evanston Location

To what extent is the self shaped by the social world in which it develops? And to what extent is that social shaping of the self recognized by theory and training in psychotherapy?

From the beginning, the vision of personality in psychoanalysis, and the various schools that evolved out of and around it, focused mainly on dynamics within a limited field of relationships: the attachment dyad, the Oedipal triad, the family system. This view of human nature, valuable as it can be, fails to give proper proportion to the person in society—and society in the person. The neural networks of the brain form in neuroplastic response to impacts from many people, and many subcultures of society, from the block to the school, the church or temple, the workplace, the ethnic culture, the nation and beyond. The relationship of the individual to society becomes particularly salient for psychotherapy when the client’s self has developed in a disempowering social context. Relational-Cultural Theory (RCT) grew out of the recognition that the central role of relationships, particularly in the lives of women and minorities, and the experience of inequality in relationships, needed to be appreciated for counseling/psychotherapy to be adequate to the needs of clients with these experiences.

In today’s Conversation we will consider the traditional view of self in psychotherapy, then look again in the light of RCT, and see whether that brings us toward a more comprehensive view of human nature from which to ground ourselves as therapists.

Shunda McGriff, M.S. Counseling, LPC, NCC is currently a doctoral candidate at Governors State University in the Counselor Education and Supervision program. She is a 2014-2015 National Board for Certified Counselors (NBCC) Minority Fellowship Program (MFP) Fellow. Professionally, Shunda has worked as a college counselor for 15 years with low-income, first-generation, and minority student populations. Jay Einhorn, Ph.D., LCPC, is President of the Chicago Association for Psychoanalytic Psychology, a therapist in private practice in Evanston and Glencoe, consulting psychologist at Roycemore School, and a supervisor in the counseling program at the Family Institute.

Shame is emerging as one of the most important and overlooked emotions in mental and emotional suffering, both among psychotherapists and the public. Shame is both a form of mental and emotional pain, and a major obstacle to psychological healing. Psychological work on ourselves needs detachment, self-observation, and acknowledgement of what we are feeling; all of which shame prevents. Shame can evoke the grief of being utterly alone, unworthy and incapable of authentic relationship with others, and can also drive rage, as the pain is directed away from the self and externalized and projected out onto others.

But there is more to shame than meets the eye. Although shame tends to be labeled in therapeutic circles as a negative emotion, and in therapy it is often true that shame both creates emotional disorder and prevents therapeutic growth, I think we need to see shame in a larger context. All our emotions and reactions have been selected by evolution, so shame must have made an important contribution to human survival over the long trek of human history.

Shame is a way of getting people to behave in conformity with what a group needs, or thinks it needs. Group cohesion was (and is!) essential for human survival, and shame is a way of getting the individual to fit in. Shame is also a way of maintaining attachment to the group. If members act in ways that threaten the cohesion and survival of the group, they can be shamed into changing back into acceptable ways of behaving by being threatened with the loss of attachment. Institutions use shame to get members to conform. Parents use shame to get children to conform. People use shame to get each other to conform.

Now, there are two main problems with this. The first one is that conditions can change, so that the patterns of behavior and belief that groups have used to survive no longer are adaptive, but instead become counterproductive. But the group still goes on, shaming members into conformity. Those who defy the group norms have to deal with the attempts of the group to shame them. This applies to small groups like families, as well as to larger communities and groups.

The second problem is that groups that were formerly better organized and functioning may become deteriorated, corrupted, and dysfunctional. Authority figures who were effective leaders may decline morally or cognitively, or may be replaced by others who are more dangerously stupid and/or corrupt. The hierarchy may become mindless and insipid, and groups which had been adaptive and furthering of their members’ human needs instead become obstacles and problems. But the group, through its members, will still shame members who speak out into conformity; “If you don’t do it our way you are not one of us.” During the Vietnam War, protesters were admonished to “love it or leave it.”

The story of “The Emperor’s New Clothes” is an example of this. Although the emperor was naked, the courtiers and subjects all told him how magnificent his robe was; coerced by shame, and perhaps also the fear of consequences.

This week I attended a presentation entitled: “Resilience to Shame: Getting to Authenticity,” by Deerfield social worker Margaret Moore (margaretmooremsw@aol.com/ 8473909145). Moore sees shame as interfering with our living fully and authentically, interfering with our ability to be fully present, and, preventing clients from making full use of therapy. She spoke of a case in which the client had completed therapy, apparently doing well, and then returned, years later, to work on another issue which she had never even brought up, because it was too shameful at the time.

Moore, who presented at the Gifted Center of the North Shore (as part of a series hosted by Gifted Center Director Noriko Martinez, 8473728134, nmartinez@giftedlearningcenter.org) referred to the work of Brene Brown on shame, vulnerability, and shame resilience. Brown has become a leading voice on this topic, with several TED talks, books, etc.

Some key points from Moore’s presentation handout:

• Shame is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging. Women often experience shame when they are entangled in a web of layered, conflicting and competing social-community expectations. Men experience shame when they are ranked, or judged to be less than powerful and strong.

• Shame is different than guilt: “I am a mistake” (shame) vs. “I made a mistake” (guilt).

• Empathy is more than words. It takes work, to see the world as others do, to be non-judgmental, to understand another peson’s feelings, to communicate your understanding of that person’s feelings.

• People who demonstrate high levels of shame resilience share four elements in their lives: the ability to recognize and understand their shame triggers, high levels of critical awareness about their shame web, the willingness to reach out to others, and the ability to “speak shame,” (being able to talk about shameful feelings and situations).

• Shame is the biggest obstacle to authenticity, and living authentically is the “noble goal.”

I appreciated Moore’s focus on shame, and certainly see it as an obstacle to authenticity and therapeutic growth. Her presentation helped me become more aware of the pervasiveness of shame, both in society and in individuals, and to be more aware of it in my own self-work and my work with clients. But I think we miss something if we stop at shame and don’t look at what’s beneath it; which is the urgent need to attach to others. Our need to attach is so strong that we will split off or disown parts of ourselves to do it. When we are subject to disabling shame, we have already made a sort of transaction, trading integrity for acceptability—because we authentically needed to be accepted. The need to attach, to belong, etc., is as authentic as the parts of ourselves that we disown in order to achieve it; and often more powerful, which is why attachment wins out over integrity. Of course that contributes to splits in the personality, the understanding and healing of which psychodynamic therapy is all about.

Affective neuroscientist Jaak Panksepp and psychoanalytic therapist Lucy Biven, in their The Archaeology of Mind, describe the basic affective state of “panic/grief,” which is a “separation distress” system. When it is overwhelmed, “one experiences a deep psychic wound–an internal psychological experience of pain that has no obvious physical cause.” Spelling the system in capitals, Panksepp and Biven state, “The PANIC/GRIEF system helps facilitate positive social bonding…because social bonds alleviate this psychic pain…” This need is one we share with animals, and it is directly connected with the evolutionary need of individuals to survive as part of a group. “When people or animals are deprived of love and acceptance, when they are spurned and forced into lower echelons of a social hierarchy where they have few rights and fewer pleasures, this is often emotionally damaging” (p. 156). Thus, the child, or adult, in separation distress may bond with an adult, or a cult-like group or organization, to alleviate that distress, even at the cost of disowning authentic parts of the self. Better fragmented but attached than isolated, seems to be the emotional rule here.

Even though modern culture seems to value and encourage independence, in fact it cultivates intense conformity. Shame—the emotion of feeling extruded and excluded from the group, or key attachment figures–such as parents and high-status peers–is a key emotion by means of which conformity is established and maintained, through the manipulation of separation distress, which Panksepp and Biven call the PANIC/GRIEF system. Of course families, schools, peer groups, faith communities, as well as the larger society, all tend to work like this. And when so many groups that we must affiliate with are so deeply flawed, we have what I call the insanity of modern life (see, “How I See It”).

One of the ways therapy works is by providing an alternative relationship within which the client can establish attachment in ways which allow, recognize and appreciate parts or aspects of themselves that they’ve had to split off or disown as the price of forming earlier attachment relationships.

(This column is Dr. Einhorn’s article in the current Cappstone, the newsletter of the Chicago Association for Psychoanalytic Psychology. Dr. Einhorn is Chair of the Advocating Psychotherapy project at CAPP. To arrange for a presentation about psychotherapy, contact Dr. Einhorn through the website contact link.)

In this time of the prevalence of a one-dimensional medical model of mental suffering and treatment, and the increasing marginalization of psychotherapy as health care reorganizes under intense economic pressures, a colleague has advanced, and perhaps also hindered, the cause of advocating psychotherapy, in a recent column in the New York Times (9-29-13). Op-Ed contributor Brandan A. Gaudano, clinical psychologist at Brown University, writing on “Psychotherapy’s Image Problem,” begins by pointing out that “In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent,” despite the fact that “a recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.” “As well they should,” he continues, “…Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.” (entire article at: http://www.nytimes.com/2013/09/30/opinion/psychotherapys-image-problem.html?emc=eta1&_r=1&/)

Dr. Gaudano attributes “the gap between what people might prefer and benefit from, and what they get,” to the fact that “psychotherapy has an image problem.” And what is that problem? “Primary care physicians, insurers, policy makers, the public and even many therapists are unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries–industries that, not incidentally, also have the money to aggressively market and lobby for those practices.”

So far so good. We heartily agree with Dr. Gaudano’s comments, which are entirely in harmony with the perspective of CAPP’s Advocating Psychotherapy project. But when it comes to identifying what constitutes effectiveness in psychotherapy, Dr. Gaudano is beating the drum of randomized controlled trials. “For patients with the most common conditions, like depression and anxiety, empirically supported psycho- therapies–that is, those shown to be safe and effective in randomized controlled trials–are indeed the best treatments of first choice.” Referring to a recent survey that he completed with his colleague Ivan W. Miller, for the November edition of Clinical Psychology Review, Dr. Gaudano states that “It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).”

“Psychotherapy’s problems come as much from within as from without,” Dr. Gaudano states. “Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which–like some old-fashioned Freudian therapies–should be abandoned.”

Here, I am afraid that some of Dr. Gaudano’s comments tend to muddy the waters about what psychotherapy is and how it can be of value, at the same time that he’s trying to clear them up. For example:

•The use of randomized controlled trials (RCT) as the “gold standard” of outcome study is misleading. RCT requires the standardization of patients into relatively pure diagnostic groups (depression, anxiety, etc., with careful pre-screening to have as close as possible to “pure” diagnostic groups) and therapies into methods defined by techniques (cognitive-behavioral, interpersonal, etc.), overlooking the individuality of patients, therapists, and patient-therapist pairs. Such clarity, simplicity and replicability are not found in the real world, in which patients are usually quite complex, therapists have to adapt whatever methods they are using accordingly, and the interaction between patient complexity and therapist adaptability often has more to do with outcome than diagnosis or treatment method per se.

•The largest contributor to outcome in therapy is quality of relationship between client and therapist (as Jonathan Shedler described in his overview of studies, “The Efficacy of Psychodynamic Psychotherapy,” in American Psychologist (Feb-Mar. 2010). This is not to dismiss the importance of methods and techniques, or the value of a well-stocked toolbag for therapists with more than a narrow specialization. But the methods and techniques are applied within a relational context, which has as much to do with their efficacy as technical skill per se.

•The practice of treating psychodynamic, cognitive, interpersonal, etc., interventions as if they are separate is misleading. I’ve never seen any successful therapy in which unconscious factors in the patient weren’t elicited and transformed, in which the patient didn’t learn to think and perceive differently, and in which the interpersonal life of the patient wasn’t in some ways altered for the better through interaction with the therapist.

•A key mistake, often repeated in the history of modern psychology, has been to reduce our understanding of human behavior and experience to the currently available scientifically accepted methods. “Science” does not mean “whatever we can study with RCT.”

•While it’s good to see psychodynamic therapy included in the winner’s circle of empirically proven methods, the emphasis on short-term therapy overlooks the need of many patients for longer-term work. Symptoms may be resistant to treatment, and can change into a focus on underlying existential issues as therapy proceeds; all of which can take a lot longer than 20 weeks.

•Dr. Gaudano’s assertion that empirically supported therapies are superior to medication still takes place within the medical model, in which mental and emotional disorders are disconnected from the facts and experiences of people’s lives. “Safe and effective” are statistical abstractions within this model. In practice, what is safe and effective for one person may not be for another; thus the lengthy caveats about problems with safety and/or effectiveness in medication advertisements.

As to “psychotherapy’s image problems,” psychoanalytic authorities and institutions have certainly contributed to them, but so have proponents of “empirically validated” treatments. In fact, just about every form of treatment in the field of psychotherapy has been heavily influenced by gifted authoritarian empire-builders and their followers, resulting in a mine field of claims and counterclaims, in which conviction based on reductionist thinking at the expense of wider truth, together with contemptuous dismissal of alternative paradigms, is the currency of the realm. There is no “one size fits all” therapy, or therapist, or method of determining efficacy.

This mine field is the main “image problem” of psychotherapy. The basic method of therapy, in which two people meet to discuss, and try to understand and resolve or improve on, the mental, emotional, and relational problems of one of them, during which they form a particular kind of working relationship which evolves if the work goes well enough–and each of those relationships is unique–continues to be more powerful than the ability of any theoretical model to explain.

Neuroscientific advances will contribute to our understanding of what’s happening in psychotherapy. Neuropsychologist Elkhonon Goldberg, in his The New Executive Brain, states that “even relatively brief but sustained cognitive activity is capable of affecting brain morphology and is detectable in neuroanatomically specific ways” (p. 239). Goldberg is talking about kinds of learning such as new languages or music, but the application to therapy is clear. All this work between patient and therapist, when effective, cultivates salutary brain changes in the patient; and perhaps also, to a lesser extent, in the therapist. Research in this area is already proceeding, although the methods and conceptual frameworks remain relatively crude. Such research, when it reaches maturity, has the potential to reformulate how we understand schools and methods of therapy.

In wider perspective, we can see that therapy and medication, mental and emotional disorders, have all evolved within our society, where rhetoric and practice in politics, education, economics, medicine, the military, religion, government, and business, are characterized by misleading oversimplifications, dogma and ritual mistaken for knowledge and truth, turf wars, cult-like processes, and successive fads; each claiming superiority until it, too, is debunked. And the people, including professionals as well as consumers in each field, tend to be blind to the process itself, caught up in the cycle of fads, one after another. Why should psychotherapy be any different?

What’s needed, across the board, is better information and better informed consumers and practitioners. Now that’s a long-term process; it will probably take more than 20 weeks. But contributing toward it, in whatever ways we can, is the goal of our little Advocating Psychotherapy project here at CAPP.